An article in the prestigious newspaper, Weekend Australian, 19 May 2012, written by Sue Dunlevy and entitled “Medical ‘Bible’ Squabble,” reports that friction over the proposed new Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association (APA) has spilled into the public arena, including some well-publicised disputes in Australia. An Australian specialist who chairs one of the committees involved in the revision, Prof. Gavin Andrews, of Sydney, has said this is rather surprising as the DSM is an American publication which has no legal standing in this country.
However, he feels it is accepted here as it is “more informative,” since each disorder is described in up to 2000 words and is therefore more helpful to doctors than, say, the World Health Organization (WHO) classification system (ICD-10). Prof. Andrews feels that the fact that the APA has accepted changes to its proposals “says that the process (of consultation) is working.” He continued: “Science says, here’s a good idea, let’s test it. Then science says, no, its unreliable, and you drop it.” He also rejected critics who urged psychiatry to incorporate non-psychiatric views, as the DSM review process involves psychologists, social workers and nurses.
Putting aside the endless faults and failings of the entire DSM project, this is a little disingenuous of Prof. Andrews for a number of reasons. Firstly, even though it had much the same descriptions as the present version, the original DSM-III was largely ignored throughout the world, partly because of its peculiar coding system. When the APA realised they were not winning the international battle for the minds of psychiatrists, they changed their coding system so that it matched the WHO codes and could be used interchangeably. Then they insisted that all papers published in their journals, and all applications for research grants, etc., had to use their classification system which meant that everybody had to fall into line. The same thing happened in Australia. A paper I wrote in 1995 was rejected by the Australian and New Zealand Journal of Psychiatry (ANZJP) just because I did not use the American system of classification. The fact that DSM-IIIR did not include the well-established diagnosis I was using didn’t matter.
The editors of the Australian psychiatric journals, all of whom have been very well known to Prof. Andrews for decades, if not close friends, had unilaterally decided that this was the way to go. Similarly, under pressure from academic psychiatrists, who cannot get ahead internationally if they do not embrace the American system, the Australian Dept. for Veterans Affairs (DVA) swapped to the US system some years ago. Part of the reason was that DVA statistics could not be used for publication in American journals unless they used the DSM system. The Australian legal system has de facto adopted the US system just because it comes with a simple-minded “recipe book” that facilitates the mindless hair-splitting that allows lawyers to upend clinical reality (and charge big fees in the process). Psychologists, nurses and schoolteachers love it because it allows them to talk “doctor-speak” without the trouble of learning what it means.
Second, DSM is not used because it is more informative, it is used because it is now all but impossible to get a textbook which does not rely it, the reason being that the huge, tentacular APA publishing business writes most of the textbooks so that they can only be read in conjuction with their DSM. DSM supports the textbooks, the textbooks support DSM, psychiatric journals demand DSM (especially those owned by the APA), editors support academics and academics support anybody who holds the purse strings. The entire system is now totally incestuous. Bringing foreign academics into the review system is just part of the process of giving it an international veneer, of making it more acceptable and, coincidentally, more profitable.
Moreover, the drug industry has been very active, more or less ghost-writing some of the elementary textbooks that medical students and general practitioners (GPs) use. Overwhelmingly, students and GPs do not read DSM, they read only what some industry insider tells them DSM says. Consider one example, which sells for $78.00 on Amazon today. This has been around for years and has sold perhaps 100,000 copies, a handy sum of money for the authors. It was written for them by drug company employees. So the drug companies get their biased and unscientific message placed exactly where they want it (with students and GPs), the alleged authors get the $7.8million in sales and, most astounding and laudable of all, the medical students get to pay for the propaganda. This is correct. In a move that must have Joseph Goebells spinning in envy in his grave, the victims of the propaganda willingly shell out all the costs of their own brain washing. It would be funny if it were not so diabolical. The authors, by the way, figured very highly in the recent Grassley inquiry into illicit payments to senior psychiatrists by drug companies. Clearly, having friends in rich places has its benefits.
This is in addition to a general program of drug companies bribing senior academics to publish papers favorable to them, or to suppress unfavorable results. Untold millions upon millions of dollars change hands to ensure that only one version of psychiatry is visible. Time and time again, the subterranean financial ties of members of the DSM committees to drug companies have been exposed but this is brushed aside as a bit of querulous nit-picking by people who are “unfamiliar with the process.” The reason people may be unfamiliar is wholly because of the pathological secrecy that surrounds the entire DSM industry, secrecy that has provoked two former chairmen of the “task force” to speak out in public. The easiest way to stop querulous nit-picking is to throw the whole process open to public scrutiny at all stages, but this is exactly what the insiders don’t want.
As for Prof. Andrews, he is not altogether a suitable person to be talking about what “science” says (we can overlook the schoolboy crudity of his soundbite). He knows perfectly well that the entire process of the DSM industry has no scientific basis whatsoever. This is because DSM does not address a formal model of mental disorder. It is mere description, still stuck at the same level as 17th century natural philosophy that classed whales as fish because they lived in water.
Prof. Gavin Andrews also does not have at his disposal an articulated, scientific model of mental disorder. Some years ago, he was invited to name the model of mental disorder he used in his daily practice, his teaching and research. He declined, but in a manner which indicated clearly that he did not have a model, he knew he didn’t have a model, and he didn’t want anybody to know he didn’t have a model. He still doesn’t, but he is safe when talking to American psychiatrists as they don’t, either, except there is a tacit agreement that nobody will ever mention this yawning gap in their intellectual development. The DSM project is not science: it is an exercise in the politics of committees, driven by academic egos and drug company money (with a very profitable sideline in publishing). The suggestion that psychologists and nurses can influence it is risible: the APA owns it outright and doesn’t share with anybody who isn’t already on board. There are no critics on the DSM task force, only Yes-people.
Andrews is not, however, alone. A recent president of the Royal Australian and New Zealand College of Psychiatrists declined to participate in a public debate on the same topic (“The College of Psychiatrists does not have a scientific model of mental disorder to guide daily psychiatric practice, teaching or research”). He also declined, saying: “…it is not appropriate to discuss such matters in public.” He suggested that this topic might be better raised in the pages of the College journals but he knew he was on safe ground there, as the editors of the College journals do not publish criticism of the path they have unilaterally chosen for psychiatry.
Between Jan. 1996 and Dec. 2005, the ANZJP published 1196 original articles. Only three of them could be considered critical of the psychiatric establishment’s vision of psychiatry. Two of them were by overseas authors, and one was mine (I showed that the so-called Biopsychosocial Model, which the College had adopted as its leitmotiv, did not exist). Unfortunately, my paper was neutered to some extent by two commissioned commentaries which denigrated but failed to address my point. My mild reply to the commentaries, pointing out their many remarkable errors and misrepresentations, was not published.
This means that the annual rate of criticism of mainstream psychiatry by psychiatrists in this country is 0.00027 papers per psychiatrist per year. When you recall that criticism of the status quo is one of the primary duties of any scientist, this score is a little underwhelming. In order to accumulate an average of one critical paper per member of the College, we would need to hang around for 30,000 years.
The suggestion by Prof. Andrews, that modern psychiatry is somehow following a valid and ethical scientific path in the DSM-5 project, cannot be taken seriously. It is simply part of the endless flood of self-serving propaganda from a small, self-appointed elitist group who feel that their crude concept of psychiatry must reign, and all dissent must be actively suppressed. If he disagrees with my gloomy assessment, he is more than welcome to join a public debate on this topic. Anywhere, any time, but could we make it sometime in the next 30,000 years?
Niall McLaren is a psychiatrist in Australia.